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	 <TITLE>Families with Children from China: British Columbia  -- Application form</TITLE> 
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		<H2 ALIGN="CENTER"> APPLICATION FOR FAMILY MEMBERSHIP*<BR> <I><FONT SIZE="2">*(Call 604-875-1607 for different form for NON-FAMILY MEMBERSHIP
		  APPLICATION)</FONT></I></H2> </CENTER> 
	 <CENTER> 
		<H3 ALIGN="CENTER"> FAMILIES WITH CHILDREN ADOPTED IN CHINA - <BR>
		  BRITISH COLUMBIA CHAPTER <BR> (FCC BC)</H3> </CENTER> 
	 <P> FCC BC is an affiliation of families in British
		Columbia with children adopted in China. FCC BC is affiliated with FCC's in other parts of North America and
		elsewhere and with the Adoptive Parents Association of British Columbia
		(APABC). </P> 
	 <P> <FONT SIZE="4" COLOR="#cc17a9">Please print out this form and mail it
		along with a cheque for $15</FONT><FONT COLOR="#cc17a9"> </FONT>(in Canadian
		funds or equivalent in US funds after exchange) to:</P> 
	 <BLOCKQUOTE> <I>FCC BC Membership - Peter Gibson
		</I><BR> <I>218 W. 23rd Ave. </I><BR> <I>Vancouver, B.C. V5Y
		2H3</I></BLOCKQUOTE> 
	 <P> Fees are for 2001 calendar year. A summary accounting of sources and
		uses of FCC BC funds will appear in all future issues of
		<I>Friends of the Family</I>, FCC BC's newsletter.</P>
	 <HR> 
	 <H4> ADULT FAMILY MEMBER(S)</H4> 
	 <H4> MOTHER</H4> 
	 <P> Family Name_______________________________________ <BR> Given
		Names_______________________________________</P> 
	 <P> Address Apt.No._________ Street No.______________ <BR> Street
		Name__________________________________________</P> 
	 <P> Address 2
		_______________________________________________________________________</P> 
	 <P> City/Town________________________________<BR> Prov./State______<BR>
		P.Code/Zip___________________________</P> 
	 <P> Home Tel: (______)_________________<BR> Fax:
		(______)_________________<BR> E-Mail_______________________________</P> 
	 <P> Work Tel: (______)_________________<BR> Fax:
		(______)_________________<BR> E-Mail________________________________</P> <HR> 
	 <H4> FATHER <I>(leave information item blank where information same as
		mother's)</I></H4> 
	 <P> Family Name_______________________________________ <BR> Given
		Names_______________________________________</P> 
	 <P> Address Apt.No._________ Street No.______________ <BR> Street
		Name__________________________________________</P> 
	 <P> Address 2
		_______________________________________________________________________</P> 
	 <P> City/Town________________________________<BR> Prov./State______<BR>
		P.Code/Zip___________________________</P> 
	 <P> Home Tel: (______)_________________<BR> Fax:
		(______)_________________<BR> E-Mail_______________________________</P> 
	 <P> Work Tel: (______)_________________<BR> Fax:
		(______)_________________<BR> E-Mail________________________________</P> <HR> 
	 <H4> CHILD FAMILY MEMBER(S)</H4> 
	 <H4> ELDEST CHILD LIVING WITH PARENT(S) ABOVE</H4> 
	 <P> Family Name ______________________________ <BR> Given Names
		________________________________________</P> 
	 <BLOCKQUOTE> <I>(TICK ONE OF FOLLOWING)</I> <BR> [__] Adopted in China?<BR>
		[__] Adopted elsewhere<BR> [__] Born to one/both parents above</BLOCKQUOTE> 
	 <P> Male(M) or Female(F)______ <BR> Date of Birth
		19______/________mo/_______day <BR> Date of Adoption 19______/_________mo </P> 
	 <P> Place of Birth </P> 
	 <BLOCKQUOTE> City/town _______________________<BR> Prov/state
		_______________________<BR> Country _________________________</BLOCKQUOTE> 
	 <P> Address same as:</P> 
	 <BLOCKQUOTE> <I>(TICK ONE)</I> <BR> [__] Both parents as above <BR> [__]
		Mother as above<BR> [__] Father as above</BLOCKQUOTE> <HR> 
	 <H4> SECOND ELDEST CHILD LIVING WITH PARENT(S) ABOVE</H4> 
	 <P> Family Name ______________________________ <BR> Given Names
		________________________________________</P> 
	 <BLOCKQUOTE> <I>(TICK ONE OF FOLLOWING)</I> <BR> [__] Adopted in China?<BR>
		[__] Adopted elsewhere<BR> [__] Born to one/both parents above</BLOCKQUOTE> 
	 <P> Male(M) or Female(F)______ <BR> Date of Birth
		19______/________mo/_______day <BR> Date of Adoption 19______/_________mo </P> 
	 <P> Place of Birth </P> 
	 <BLOCKQUOTE> City/town _______________________<BR> Prov/state
		_______________________<BR> Country _________________________</BLOCKQUOTE> 
	 <P> Address same as:</P> 
	 <BLOCKQUOTE> <I>(TICK ONE)</I> <BR> [__] Both parents as above <BR> [__]
		Mother as above<BR> [__] Father as above</BLOCKQUOTE> 
	 <P> </P> <HR> 
	 <H4> THIRD ELDEST CHILD LIVING WITH PARENT(S) ABOVE</H4> 
	 <P> Family Name ______________________________ <BR> Given Names
		________________________________________</P> 
	 <BLOCKQUOTE> <I>(TICK ONE OF FOLLOWING)</I> <BR> [__] Adopted in China?<BR>
		[__] Adopted elsewhere<BR> [__] Born to one/both parents above</BLOCKQUOTE> 
	 <P> Male(M) or Female(F)______ <BR> Date of Birth
		19______/________mo/_______day <BR> Date of Adoption 19______/_________mo </P> 
	 <P> Place of Birth </P> 
	 <BLOCKQUOTE> City/town _______________________<BR> Prov/state
		_______________________<BR> Country _________________________</BLOCKQUOTE> 
	 <P> Address same as:</P> 
	 <BLOCKQUOTE> <I>(TICK ONE)</I> <BR> [__] Both parents as above <BR> [__]
		Mother as above<BR> [__] Father as above</BLOCKQUOTE> 
	 <P> </P> <HR> 
	 <H4> FOURTH ELDEST CHILD LIVING WITH PARENT(S) ABOVE</H4> 
	 <P> Family Name ______________________________ <BR> Given Names
		________________________________________</P> 
	 <BLOCKQUOTE> <I>(TICK ONE OF FOLLOWING)</I> <BR> [__] Adopted in China?<BR>
		[__] Adopted elsewhere<BR> [__] Born to one/both parents above</BLOCKQUOTE> 
	 <P> Male(M) or Female(F)______ <BR> Date of Birth
		19______/________mo/_______day <BR> Date of Adoption 19______/_________mo </P> 
	 <P> Place of Birth </P> 
	 <BLOCKQUOTE> City/town _______________________<BR> Prov/state
		_______________________<BR> Country _________________________</BLOCKQUOTE> 
	 <P> Address same as:</P> 
	 <BLOCKQUOTE> <I>(TICK ONE)</I> <BR> [__] Both parents as above <BR> [__]
		Mother as above<BR> [__] Father as above</BLOCKQUOTE> <HR> 
	 <BLOCKQUOTE> <I>(TICK ONE) </I></BLOCKQUOTE> 
	 <UL> 
		<LI> Yes [___] No [___] Are you waiting to adopt a child from China?
		  </LI> 
		<LI> Yes [___] No [___] May we include some or all of this information in
		  a directory for issue to members only? </LI> 
	 </UL> 
	 <P> Would you be prepared to assist FCC at some time with any of the
		following? </P> 
	 <BLOCKQUOTE> <I>(TICK AS APPLICABLE)</I> </BLOCKQUOTE> 
	 <UL> 
		<LI> Yes [___] No [___] Organizing events (picnics, Chinese New Year
		  celebration, etc) </LI> 
		<LI> Yes [___] No [___] Writing newsletter articles </LI> 
		<LI> Yes [___] No [___] Calling </LI> 
		<LI> Yes [___] No [___] Mailouts </LI> 
		<LI> Yes [___] No [___] Editing Newsletter </LI> 
		<LI> Yes [___] No [___] Typing/data entry </LI> 
		<LI> Yes [___] No [___] Collecting money or charity items </LI> 
		<LI> Yes [___] No [___] Standing for nomination for co-chair or other
		  elected role </LI> 
		<LI> Yes [___] No [___] Taking on an appointed role, eg. local contact,
		  treasurer </LI> 
		<LI> Yes [___] No [___] Other <I>(SPECIFY)</I>
		  ___________________________________________<BR>
		  __________________________________________________________________________
		  </LI> 
		<LI> Yes [___] No [___] Do you have any skills or experience that may be
		  useful to FCC BC? <I>(PLEASE SPECIFY)</I>
		  ________________________________________________<BR>
		  __________________________________________________________________________<BR>
		  __________________________________________________________________________
		  </LI> 
	 </UL> 
	 <P> Any comments or questions?<BR>
		_______________________________________________________________________________
		<BR>
		_______________________________________________________________________________
		<BR>
		_______________________________________________________________________________
		<BR>
		_______________________________________________________________________________
		<BR>
		_______________________________________________________________________________
		</P> <HR> 
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